Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
Br J Surg. 2011 Oct;98(10):1431-6. doi: 10.1002/bjs.7576. Epub 2011 Jun 1.
Operative notes represent an essential element in safe patient care and should therefore be clear and accurate. This comparative study examined whether operative notes accurately represented the laparoscopic cholecystectomy (LC) as performed.
Nine Dutch teaching and non-teaching hospitals were invited to record 20 successive LCs each and to collect the corresponding operative notes. The main outcome measures were overall differences and correspondence between video recordings and notes based on the Dutch guideline for LC and the occurrence of iatrogenic gallbladder perforation. A comparison was made of the cumulative results of recordings and operative notes, and individual recordings were compared with the corresponding notes.
Seven hospitals participated in the study; 125 video recordings and operative notes were fully analysed. Recordings showed more steps of the procedure than did notes. Individual comparisons showed significant differences (P≤0·001) between the recording and the corresponding note for the steps 'Introducing trocars under vision', 'Condition of the gallbladder', 'Critical view of safety' and 'Removing first and second trocar under vision'. Iatrogenic gallbladder perforation with spilled bile occurred in 31 patients (24·8 per cent), and was both recorded and reported in 29 patients. Iatrogenic gallbladder perforation with spilled bile and spilled stones occurred in 15 patients (12·0 per cent), and was recorded and reported in 11 patients.
Operative notes do not adequately represent the actual LCs performed as they describe fewer important procedural steps. It is suggested that operative notes should include video recordings.
手术记录是患者安全护理的重要组成部分，因此应该清晰准确。本对照研究旨在检查手术记录是否准确反映了实际进行的腹腔镜胆囊切除术（LC）。
邀请 9 家荷兰教学和非教学医院各记录 20 例连续 LC，并收集相应的手术记录。主要观察指标是基于荷兰 LC 指南的视频记录和记录之间的整体差异和一致性，以及医源性胆囊穿孔的发生。对记录和手术记录的累积结果进行比较，并对个别记录与相应记录进行比较。
7 家医院参与了该研究；对 125 份视频记录和手术记录进行了全面分析。记录显示的手术步骤多于记录。个体比较显示，记录与相应记录在“在可视条件下引入套管针”、“胆囊状况”、“安全关键视图”和“在可视条件下取出第一和第二套管针”这几个步骤上存在显著差异（P≤0·001）。31 例（24.8%）患者发生医源性胆囊穿孔并胆汁溢出，29 例患者记录并报告了该并发症。15 例（12.0%）患者发生医源性胆囊穿孔伴胆汁和结石溢出，11 例患者记录并报告了该并发症。
手术记录没有充分反映实际进行的 LC，因为它们描述的重要手术步骤较少。建议手术记录应包括视频记录。
